6 Common Concerns Regarding Medical Marijuana

Patients—CASH:

Cost, Administration, Social Stigma, and High Feeling

#1 Cost

The fact that medical cannabis is usually not covered by insurance plans in Canada may cause significant concern for those who are often disabled, chronic pain patients, retired, or unable to work.1 Fortunately, many organizations have assisted pricing plans for individuals with demonstrable financial need. More recently, Canadian Veterans Affairs is covering this for veterans with post-traumatic stress disorder.

#2 Administration Routes

Many chronic pain patients lack experience with using cannabis. They may lack knowledge of procedures in obtaining and using cannabis via different routes of administration. Instructions for purchasing, grinding/milling, weighing, vaporization, joint rolling, and derivative making may be necessary for a more informed use of cannabis. Newly prescribed patients must be familiarized with practical and legal limitations, including barriers to traveling with the medication.

#3 Social Stigma

Many chronic pain patients contemplating medical cannabis may fear getting criticized by their friends and family. Some patients may not share their cannabis use with loved ones even after seeing improvements in their pain management and quality of life. These concerns stem from societal stigmatization of marijuana and can often be resolved by enabling patients to medicalize their approach to disclosure.

Patients are successful by explaining to friends and family that cannabis has been prescribed to them as a medicine to treat their condition. Empowering patients with evidence-based knowledge may help with this communication process. In March 2016, the Canadian government approved the use of cannabis oils across Canada.2 With its recent approval, patient concern about leaving an obvious smell from smoking or vaporization will also be mitigated.

#4 “High” Feeling

Contrary to the common belief about patients seeking access to medical cannabis, many patients prefer to avoid “ feeling high.” The high THC content of strains has been shown to be associated with such psychoactive effects. Further, CBD is an antagonist to the psychoactive effects of THC. Thus, by manipulating the levels of THC and CBD, the prescriber can easily mitigate the high effects. We typically start with high CBD and low THC (preferably the CBD is 4 times or more higher than the THC). After 1 week to 1 month, the inflammation should be reduced—but if there is no change in neuropathic pain, we then gradually increase the THC up to the point where pain relief occurs with minimal or no psychoactive side effects. If sleep is an issue (or PTSD), then higher THC works better (as a night-specific presleep strain). Licensed producers/dispensers, such as MedReleaf, Tilray, and Mettrum, have the highest THC content (about 27% THC compared with 1% or lower CBD).

Strains of cannabis containing high levels of CBD generally make patients feel less high.3 A number of high-CBD, low-THC strains are available for patients concerned about feelings of euphoria and highness. As of May 2016, Mettrum, Bedrocan, CanniMed, and Tweed are licensed producers authorized to make CBD oils and products with a high CBD content (about 20% CBD compared with 1% or lower THC). 2 It is expected that other producers will soon be given Health Canada authorization.

Physicians

#5 Credibility—Criminality—Clinical Evidence

In 2014, over 1,800 studies were published on cannabinoids (endogenous, phytologic, pharmaceutical). To date, 107 cannabinoids have been identified with about 420 chemicals in the marijuana plant. The growth of knowledge in this field has resulted in a change in attitude toward medical cannabis. A classic example was the CNN apology by Dr. Sanjay Gupta in 2009 (Updated, August 8, 2013) moving toward greater acceptance of such medicinal benefits.4 There is also the need to distill such information into constantly updated evidence-based guidelines and practical steps toward optimizing patient care and quality of life.

#6 Patient Addiction

According to a study, 1 in every 11 individuals using cannabis (9%) will become dependent on the drug.5 The cumulative probability estimate of transition to dependence was 67.5% for nicotine users, 22.7% for alcohol users, 20.9% for cocaine users, and 8.9% for cannabis users. Unfortunately, the study included participants that consumed all types of cannabis without considering the purpose for consumption (medical or nonmedical) and strain.

Regardless, a dependence prevalence of 9% is still significantly lower than those reported for approved prescription medications commonly used for chronic pain management. A study of benzodiazepines, which are widely prescribed, noted that even short-term use is associated with the development of physical dependence, “with between 15% to 44% of chronic benzodiazepine users experiencing protracted moderate to severe withdrawal symptoms upon cessation, including emergent anxiety and depressive symptoms.”6 Estimates of addiction among chronic pain patients vary widely, from about 3% to 40%. This variability is the result of differences in treatment duration, insufficient research on long-term outcomes, and disparate study populations and measures used to assess abuse or addiction.7

Monitoring for cannabis dependency is recommended for all patients, especially for those on higher THC treatment.

Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130.

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